Wednesday, July 8, 2009

"Old Friends" Battle it out Over DSM-V Psychosis

Yesterday, Psychiatric Times published this response to the Allen Frances critique of DSM-V. It is written by William Carpenter, who is Professor of Psychiatry at the University of Maryland, and the chairman of the DSM-V work group on psychosis.

Carpenter begins his response by saying that Allen Frances is an "old friend," although from the tenor of this article, "old" may be the operative word. I know Dr. Carpenter myself, having interviewed him for the March 2007 issue of The Carlat Psychiatry Report, and having chatted with him here and there at APA meetings. He's a southern gentleman, and I found him very forthcoming and honest about a range of issues, including his refreshing skepticism of the value of some of the newer atypical antipsychotics. He has done some consultation with drug companies but very little over the past few years. He's definitely no hired gun, and he speaks his own mind.

The bottom line is that Dr. Carpenter is extremely credible and anything he says or writes you have take seriously. And if you were to boil down his response to Dr. Frances to a few sentences, it would be:

"In actuality, there will be very few substantive changes in the DSM-V. Most of the diagnostic criteria will be the same. We might add a handful of rating scales. There will be no 'paradigm shift.' We are considering adding a sub-threshold psychosis diagnosis but then again we may not--it's a complex scientific issue and we, like you, are concerned about overdiagnosis and stigma."

Basically, Dr. Carpenter is saying that Dr. Frances has created a sensationalized straw man argument, making all kinds of predictions about DSM-V, few of which will materialize.

Of course, Carpenter is focusing on only one of many diagnostic categories, so the Frances critiques may still apply to the rest of DSM-V. Hopefully, we'll hear from the other Work Group chairs soon.

5 comments:

As a publisher and journalist who broke into the psychiatric field in 1994 when the battle-hardened DSM-IV editors were finalizing The Manual, I can offer a perspective on those politically perilous and emotionally charged days. Why this might be of interest is because history may be repeating itself.

We had just introduced a new journal to the field and one of my first interviews was of Dr. Frances. (Six months later we did a cover story on Dr. Sptizer.) Having cut my teeth at daily newspapers and at ABC/CAP Cities, I knew only too well the wary look of an interviewee who was under constant siege — and Frances had it. The level of professional scrutiny (and celebrity) he was under was enormous as part of his job was to manage a war-room-like barrage of criticism from psychiatry's "old guard," who seemed to have a vested interest in the status quo. Ultimately, the consensus is that Frances and crew did a very credible job. Perhaps, coincidentally, following the publication of the DSM-IV, both Frances and Spitzer used their new-found status to start a psychiatric journal (Frances) and to lend their name and support to a pharma-sponsored psychiatric rating scale for primary care doctors (Spitzer).

While the substantive discussion of the DSM-V is best left to DC and colleagues, after reading this most recent post on the subject and the comments of Dr. Carpenter, I couldn't help but feel "deja vu all over again." (Yogi Berra?) And though it is refreshing to see the field take a break from the bloodletting of the debate on CME sponsorship and turn to substantive matters once again, I respectfully submit to both past and present editors of the DSMs that history will, ultimately, require its dues from each and every one of you, so it may pay to be gracious, lest you find yourselves on the DSM-VI work group.

Opening the process and allowing for feedback in the development stages would do wonders in ending speculation about what might be happening behind closed doors. My fear is that a secretive process will result in a final document rife with problems which are too late to amend. Dr. Carpenter may be able to reassure regarding his work group, but that is hardly an area brimming with controversy.

Transparency of the process and early feedback, especially in those areas which are caught up in controversy, would provide for early amendment when fitting and while still possible. Nola Nordmarken MFT contributing author, Zur Institute. http://www.zurinstitute.com/dsmcritique.html